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Guidelines: Nursing and Midwifery Workforce Planning

SEA-NUR-463Distribution: General

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Guidelines: Nursing and Midwifery Workforce Planningiii

Contents

Acknowledgements ............................................................................................................... v

Preface .................................................................................................................................vii

Acronyms and abbreviations ................................................................................................viii

Executive summary ................................................................................................................ix

Introduction ..........................................................................................................................1

Purpose ........................................................................................................................1

The WHO response .....................................................................................................2

Methodology ................................................................................................................2

Workforce planning – an overview ........................................................................................4

What is workforce planning? .........................................................................................4

Why a workforce plan? .................................................................................................4

Workforce planning in nursing and midwifery ...............................................................6

A framework for workforce planning in nursing and midwifery ..............................................8

Step 1: Define scope and objectives .............................................................................9

Step 2: Establish project management .........................................................................10

Step 3: Assess the environment...................................................................................13

Step 4: Describe workforce capacity and supply .........................................................16

Step 5: Estimate future needs .....................................................................................19

Step 6: Gap analysis ..................................................................................................22

Step 7: Strategy development .....................................................................................23

Step 8: Implement ......................................................................................................28

Step 9: Monitor and evaluate .....................................................................................29

Successful workforce planning ....................................................................................30

Annexes

1. Excerpt from Regional strategic plan for health workforce development in the South-East Asia Region ......................................................................................32

2. Principles for scaling up nursing and midwifery capacity, Islamabad Declaration, 2007 ......................................................................................34

3. Examples of workforce planning guidelines, processes and resources ..........................35

Bibliography ........................................................................................................................37

References ..........................................................................................................................40

Guidelines: Nursing and Midwifery Workforce Planningiv

Guidelines: Nursing and Midwifery Workforce Planningv

Acknowledgements

Several people helped in the development of these guidelines. The World Health Organization wishes to acknowledge their contribution and expertise in putting together this document.

We would like to thank Dr Tassana Boontong, former President of Thailand Nursing and Midwifery, for sharing her vision and experience of the study entitled “Projection of nursing and midwifery workforce in Thailand in the next decade”. Her inputs provided the ground work for the project.

Appreciation and thanks are extended to Ms Bridget Weller, a manager at the International Centre of Human Resources in Nursing, International Council of Nurses, Geneva and a human resource expert based in Edinburgh, United Kingdom. This document was developed with her expertise. We would also like to thank Professor James Buchan, a senior consultant in human resources, for working with her. His valuable guidance and inputs to the development of this document are acknowledged.

We extend our sincere gratitude to participants of the Second Meeting of the Nursing and Midwifery Educational Institutes Network of the South-East Asia Region, held in April 2009 in Myanmar. Their inputs made the document more relevant to countries of the Region. Their decision to adopt the guidelines is very important.

Finally, we would like to thank Dr Bandana Malhotra for editing the document.

Nursing and Midwifery Unit Regional Office for South-East Asia

Guidelines: Nursing and Midwifery Workforce Planningvii

Preface

The health workforce is a key component of an effective health system. The nursing and midwifery workforce forms a large part of the health workforce in most countries. Nurses and midwives are present at all levels of health-care facility and in the community. Their roles and responsibilities may be varied, depending on the country’s health systems policy and context.

Numerous challenges face the nursing and midwifery workforce in countries of South-East Asia. Some of these include shortages, internal–external migration, high turnover, inadequate competency, limited career advancement and lack of a safe working environment. These challenges need to be properly tackled and managed so that the nursing and midwifery workforce can significantly contribute to achieving the Millennium Development Goals and Health for All.

The World Health Report 2006: working together for health indicates that an adequate and competent workforce leads to favourable health outcomes. There are critical shortages of doctors, nurses and midwives in 57 countries globally and, among these, six countries are in South-East Asia Region. The density of nurses and midwives per 1000 population in Bangladesh, Bhutan, India, Indonesia, Myanmar and Nepal needs to be increased.

One of the strategies that can assist countries in having the workforce required to meet the needs of health systems is to have a national health workforce plan. WHA Resolution 59.23 on “Rapid scaling up of health workforce production” and WHA 29.27 on “Strengthening nursing and midwifery” urged Member countries to develop health workforce plans and strategies. This was further emphasized at the 24th Health Ministers meeting and the 59th Regional Committee meeting held in Dhaka, Bangladesh in 2006, and in the Regional strategic plan for health workforce development in the South-East Asia Region.

WHO has been requested to provide technical support to Member countries for nursing and midwifery workforce planning as an integral part of national health workforce planning. These guidelines were developed to support the process. They aim to assist countries in planning for a nursing and midwifery workforce, and provide a broad framework and outline the steps to be taken. Due to the rapidly changing health scenario, workforce plans will have to be constantly reviewed and revised to meet the needs and resources available in a country at a particular point in time.

Dr Samlee Plianbangchang Regional Director

Guidelines: Nursing and Midwifery Workforce Planningviii

Acronyms and abbreviations

CSBA community-based skilled birthing attendant

FTE Full-time equivalent

HRH human resources for health

HRIS human resource information system

MDG Millennium Development Goal

OECD Organization for Economic Development and Co-operation

SEA South-East Asia

SEAR South-East Asia Region

SEARO Regional Office for South-East Asia (of WHO)

WHA World Health Assembly

WHO World Health Organization

Guidelines: Nursing and Midwifery Workforce Planningix

Executive summary

The World Health Organization (WHO) has noted that “almost all the countries in the Asia–Pacific region are facing several common health workforce-related problems and challenges including workforce shortage, skill-mix imbalance, maldistributions, poor work environment, and weak developing and managing capacities and knowledge bases. Those issues are currently limiting the progress towards the Millennium Development Goals (MDGs), and limiting access to effective and high-quality health services for many people.”.1 The countries in the South-East Asia (SEA) Region of WHO, and the individual health services that operate within them, share these issues.

These guidelines are intended to provide practical approaches and tools to assist managers to develop knowledge and skills in workforce planning. They aim to explain what workforce planning is, and how it can help to deliver key service delivery goals and provide better care.

Workforce planning refers to the process by which an organization or agency determines the workforce it needs to deliver its services – both now and in the future, and develops strategies that balance those workforce needs with the available workforce supply. It can be simply defined as ensuring the right practitioners are in the right place at the right time with the right skills to deliver the care.2,3,4

Workforce planning does not occur in isolation. It is part of a complex network of interrelated factors, all of which impact on planning decisions. These range from broad policy concerns to the concerns and challenges facing local communities. It aims to identify all those factors, both internal and external, which will impact on the way that nursing and midwifery services will be delivered in the short and long term.5

Guiding principles for these strategic actions is that they should be practical, deliverable and have identifiable outcomes. The strategies that are developed should not just address the immediate problem, but contribute to the long-term development of a sustainable health workforce, as well as be consistent with the organization’s goals. Importantly, they should be consistent with each other, so that each one contributes to a shared objective of a sustainable approach to health service delivery.

Guidelines: Nursing and Midwifery Workforce Planning1

Introduction

Purpose“The overall aim of the Programme for Development of Human Resources for Health (HRH) in the WHO South-East Asia Region is to collaborate with Member Countries to correctly plan, effectively train, efficiently deploy and optimally utilize the types and numbers of health personnel that they require to meet the needs of their health systems. This, in practical terms, refers to the achievement of a balance in numbers and in distribution, relevance in education and training and to ensure that they perform optimally.”6

Consistent with this goal, these Guidelines aim to assist countries of the South-East Asia Region (SEAR) to develop their approaches to nursing and midwifery workforce planning. They aim to provide

A discussion of the rationale and significance of workforce planning on health •outcomes;

A framework for nursing and midwifery workforce planning;•

A brief overview of the factors to be considered in the development of nursing and •midwifery workforce plans;

Tools and methods for calculation of demand and supply of nursing and midwifery •workforce and planning; and

Strategies to develop effective nursing and midwifery workforce planning and •implementation.

They are intended to provide practical approaches and tools to assist managers to develop knowledge and skills in workforce planning. They aim to explain what workforce planning is, and how it can help in delivering key service delivery goals and provide better care.

WHO has noted that “almost all the countries in the Asia–Pacific region are facing several common health workforce-related problems and challenges including workforce shortage, skill-mix imbalance, maldistributions, poor work environment, and weak developing and managing capacities and knowledge bases. Those issues are currently limiting the progress towards the Millennium Development Goals (MDGs), and limiting access to effective and high-quality health services for many people.”1 The countries in SEAR, and the individual health services that operate within it, share these issues. It is hoped that these guidelines will help service providers at the local level identify practical and realistic strategies to address them.

These guidelines have been developed primarily to assist health service managers, senior nurses and midwives, and other key stakeholders in health service delivery to develop their own practical, achievable and sustainable workforce plans.

It does not attempt to deal with the broader “macro” level planning issues such as government and health sector funding, overall training capacity, and global funding allocation.


The WHO responseIn 2002, the Fifty-fifth World Health Assembly (WHA) requested the Secretariat “to accelerate development of an action plan to address the ethical recruitment and distribution of skilled health care personnel, and the need for sound national policies and strategies for training and management of human resources for health”. Since that time, the WHA has adopted a series of resolutions addressing different aspects of the health workforce crisis. These include:

Resolution WHA57.19 (2004) on the challenge posed by the international migration •of health personnel;

Resolution WHA59.23 (2006) on rapid scaling up of health workforce production; •and

Resolution WHA59.27 (2006) on strengthening nursing and midwifery.•

The commitment of governments of Member countries in the SEA Region to address the challenges faced in relation to health workforce was evident at the 29th Health Ministers’ Meeting and at the 59th Regional Committee meeting held in Dhaka in 2006. The Dhaka declaration on “Strengthening health workforce in Member countries of the South-East Asia Region” and Resolution (SEA/RC 59/R6) adopted by the Regional Committee on “Strengthening the health workforce in South-East Asia” which were endorsed during these meetings is testimony to their commitment.7

WHO is working closely with Member countries in the SEA Region to build a regional health workforce that is prepared to face the ever-changing global scenario. As part of these efforts, the WHO Regional Office for South-East Asia (WHO SEARO) published the Regional strategic plan for health workforce development in the South-East Asia Region in 2007.7 This strategic plan identified goals, key result areas and principles to guide health workforce planning in the Region (see Appendix 1), including the need to develop needs-based workforce planning which “is based on sound evidence that captures the changing health needs of the population in the social–demographic and socio-cultural context of the population”.

MethodologyThere is a growing body of literature on workforce planning for health human resources. Among this is a number of guidelines and “how to” documents that have been developed, some of which are generic, others of which are targeted to specific audiences and contexts. This document draws from these available resources, many of which are available to those with access to the internet. Some examples are provided in Appendix 2. Readers who have the opportunity to access these documents are encouraged to do so.

Although there is no single approach to workforce planning which will suit every health service or context, they share a strong degree of commonality. The approach outlined here draws on all those influences and attempts to synthesize available information in a way that will be both useful and accessible for nurses, midwives, health service managers and policy-makers throughout the SEA Region.


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Workforce planning – an overview

What is workforce planning?Workforce planning refers to the process by which an organization, system or agency determines the workforce it needs to deliver its services – both now and in the future, and develops strategies that balance those workforce needs with the available workforce supply. It can be simply defined as ensuring the right practitioners are in the right place at the right time with the right skills to deliver the care required.2,3,4

In seeking to achieve this goal, a broad range of factors and influences, both internal and external, must be considered. As such, workforce planning should be interlinked with the full range of organizational planning policies such as service planning, budget planning, and training and development plans. It also must take into account the realities of available facilities and resources, the current workforce profile, and the dynamic and ongoing changes in policy and service delivery models that will influence how nursing and midwifery services are delivered.

Why a workforce plan?Successful preparation of a workforce plan is an achievement, but it is not an end in itself.8 Workforce planning is a means by which service delivery targets can be achieved, and ultimately its objective is to contribute to improving health outcomes. “There is ample evidence that worker numbers and quality are positively associated with immunization coverage, outreach of primary care, and in fact, child and maternal survival”.9

In its report Working together for health,9 WHO developed estimates of the global shortfall of health workers required to deliver the health-related MDGs.*

The report identified six of the 11 countries in the SEA Region as having a “critical shortage” of health workers, and that a 50% increase in health workers would be required in those countries to reach the threshold levels.

The report goes on to identify the scaling up of workforce planning as a key element to providing the human resources needed to achieve the MDGs. Stressing the importance of both political leadership and adequate financing, it notes that

The third requirement is a sensible strategy to boost the health workforce, one with short-term as well as longer-term performance goals. The strategy must be based on established human resources needs for priority programmes* and it must mobilize the institutions involved in both the production and management of the workforce.9

* Based on a desired level of coverage of 80% of deliveries by skilled birth attendants or for measles immunization, and on an assessment that 2.5 health-care professionals were required to meet that “threshold”.9


Good workforce planning can also play an important role in ensuring that health services are delivered effectively and efficiently, which “depends to a great extent on the effective deployment and use of personnel”.3 Commitment to short-term and long-term health workforce planning and to produce appropriately trained health workers to meet health needs have been identified as two key “critical success factors” of efforts to scale up the health workforce.10

Good workforce planning helps to ensure that skills are used where they are most needed, avoids waste and duplication, improves productivity of existing staff and enables employing organizations to better:

Project and respond to staffing needs •

Identify gaps between the skills available and the skills needed in the future•

Influence the development of new job roles and the way different cadres work •together

Inform the deployment and organization of existing staff•

Monitor and manage the cultural diversity and gender mix of staff•

Provide an orderly way to respond to internal or external changes to the environment •that impact on the workforce, and

Anticipate and manage risk, particularly in relation to disruptions to service delivery •arising from staffing problems.11,12

Workforce planning also plays a very important role in the broader context of health service planning and delivery. Effective workforce planning provides a vital source of information which can inform the development of national or local health service planning and capacity building. The role of the education and training sector is a classic example of this. Though often funded, managed and reporting to different arms of the government than the health sector, educational institutions play a vital role in training the future health workforce. While varying the number

Figure 2: Density of health workers improves health outcomes10

Source: Working together for health, WHO 2006

High

LowDensity of health workers HighLow

Maternal survival

Child survival

Infant survival

Prob

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of nurses and midwives trained is unlikely to provide the sole solution to staffing shortages,13 the close collaboration between health services and education providers is vital. “Education institutions thus need to work closely with relevant health services to identify the extent to which health service needs are changing. Health services also need close working relationships with the educational institutions that supply new entrants to their workforce.”14

Similarly, non-human resources, such as the availability of capital infrastructure, equipment and technology, will impact on the skills required of nurses and midwives in the workplace and the numbers of nurses and midwives required to deliver a particular health outcome. In addition, workforce planning occurs within a particular context of policy, economy and politics.13 Accurate information about both the volume and the nature of the future nursing and midwifery workforce will allow nurses and other health service managers to contribute to broader discussions about health service planning at all levels, including effective advocacy to ensure that there is sufficient “fiscal space” made available to deliver the workforce required to achieve key health goals.15

Effective workforce planning can play a role in improving the working lives and health and well-being of nurses and midwives, by contributing to the development of positive working environments, meaningful and valued professional roles, improved opportunities for personal and career development, and improved leadership and management. These have all been identified as key factors in retaining health service staff.16,17

Workforce planning in nursing and midwiferyAs noted by the Director-General of WHO in 2002,

“Nursing and midwifery services are a vital resource for attaining health and development targets. They form the backbone of health systems around the globe and provide a platform for efforts to tackle the diseases that cause poverty and ill-health. If we are to succeed in improving health systems performance, urgent action is needed to overcome the problems that seriously undermine the contribution these services can make to the vision of better health for all communities.18

Further, nursing and midwifery services also “complement and support other health services and thus help to ensure the successful implementation of interventions that welcome life, promote or restore health”.18

Three key areas for action in respect of nursing and midwifery were identified in the Islamabad Declaration on nursing and midwifery (2007),19 which followed a high-level global consultation hosted by the Federal Minister for Health in Pakistan, former Chair of the WHO Executive Board, and organized in collaboration with the WHO, the International Council of Nurses and the International Confederation of Midwives. The Declaration affirmed that a “coordinated, integrated, collaborative, sustainable approach to planning, policy and health-care delivery are necessary to strengthen nursing and midwifery services” and called for urgent attention in three key areas including scaling up nursing and midwifery capacity, and that workforce planning was one of the key strategies of scaling up efforts. It further stated that “each country must establish policy and practices to ensure self-sufficiency in workforce production within the limits of its own resources”.


It is important to note, however, that planning for nursing and midwifery cannot occur in isolation. As researchers such as O’Brien-Pallas et al. have noted, “health human resources planning should be broad in nature incorporating the entire health workforce”.3 Nurses and midwives work in the context of health services alongside other qualified health professionals, as well as a range of other staff based in the health services and local communities that play a vital role in delivering care, and a range of midwifery and maternal and child health services. A broad skill mix is required, and the issues facing all parts of the workforce are closely interrelated.20


A framework for workforce planning in nursing and midwifery

There are a number of key steps that can be outlined in the workforce planning process. While the way in which these steps are described and defined can vary slightly depending on the scope and purpose of the workforce planning process under discussion, nine simple key steps can be described as follows:

Agree on scope and objectives.(1)

Establish project management capacity.(2)

Assess the environment.(3)

Describe the current workforce capacity.(4)

Estimate future workforce needs.(5)

Analyse the gap between workforce requirements and workforce capacity.(6)

Develop strategies and responses to balance workforce needs with workforce (7) capacities.

Implement.(8)

Monitor and evaluate.(9)

Each of these steps is discussed in further detail in this section.

Figure 3: Nine-step workforce planning cycle

Implement

Strategydevelopment

Gap analysis

Assess theEnvironment

Estimate futureneeds

Describeworkforcecapacity

Define Scopeand Objectives

Establish ProjectManagement

Monitor andEvaluate


Step 1: Define scope and objectives

What is your objective?

It is important to have a clear idea of what the workforce planning process is aiming to achieve, and what its main focus should be. More than one objective may be taken into account.

There may be a range of issues to address, such as long-term staff vacancies and shortages, or maldistribution across rural and urban areas. In addition, very specific outcomes may be required, such as developing, recruiting and hiring the nurses and midwives required for a new service that is planned. Being clear about what you are trying to achieve will help you to engage stakeholders in the process, and make it easier to evaluate, assess and review the outcomes13.

What is the scope of the project?

There are a number of issues to be considered in determining the scope of the project. One of the most important of these is determining whether the strategies and objectives of the project will be confined to those directly affecting nurses and midwives. Most researchers agree, however, that an integrated approach to workforce planning is the ideal, and more likely to result in successful outcomes. 8,20,24

The timeframe that is being planned for should also be considered. Challenges facing the nursing and midwifery workforce may be short term, such as immediate difficulties in attracting the staff necessary to run or establish a particular service, medium term such as preparing for service developments that will occur over the next 1–3 years, and longer term, which may include preparing for anticipated changes in population health needs, or demographic changes. Critical dates in the planning timetable – such as the opening of a new facility requiring additional staff, for example – should be noted at this point.

The Australian Health Workforce Advisory Committee has documented some useful considerations when embarking on workforce planning in nursing and midwifery services:4

Will workforce planning be based on existing health-care services provision or based •on consideration of alternative service provision approaches?

Will it be integrated across all relevant professions or be profession specific?•

How will it relate to the broader health system?•

Is it focused at national, regional or local level, or a combination?•

It is concerned with only providing advice on workforce numbers (or also other •relevant issues)?

What is the timeframe?•

Objectives

Definition:

(n) A goal or aim22 (Pearsall, 2002 p.981).

Examples

“To ensure universal coverage of health services for the entire nation.”

“To train and produce all categories of human resources for health within the country23.” (Ministry of Health, Myanmar)

“Develop adequate and competent human resources to manage health programs in line with global and national health targets and strategies24” (Gross National Happiness Commission, Royal Government of Bhutan, 2009)


How will we measure success?

It is a good idea to start thinking about how you will measure your achievements. This will help you to think about who you need to involve. Also, it may help you to understand exactly what information you will need in the future, and how you are going to get it.

Step 2: Establish project managementEngaging sponsorship and support

Research has shown that one of the characteristics of successful workforce planning is the support and engagement of high-level sponsors in the organization. Securing this support early on in the project will help ensure that others in the organization become engaged in the process. It will also be invaluable once any planning project reaches the implementation stage, where managers and other staff may be required to initiate, implement and manage any related change processes. This will be much easier if they have had the opportunity to understand and input into the development from the start.

Sponsorship and support is also important in order to secure the resources required to develop the plan and build the project team. This sponsorship includes making the necessary resources and information available so that the work can be completed as required. It is important that the organization is willing to spend the resources required, commensurate with the scope of any planning approach.

ScopeDefinition:

(n) the extent of the area or subject matter that something deals with or to which it is relevant 22(Pearsall, 2002 p. 1283).

Examples

“Nursing workforce planning ...aims to cover the entire nursing workforce, and therefore incorporates both public and private sector supply and requirements.”4 (Australian Health Workforce Advisory Committee, 2004 p. 10)

“The nursing workforce in this paper referes to enroled nurses (ENs) and registered nurses (RNs) and may include those workers who support nurses in the care of patients such as assistants in nursing and patient carers.”4 (Australian Health Workforce Advisory Committee, 2004 p.10)

“It covers the second 5 year period of Myanmar Health Vision 2030”23 (Ministry of Health, Myanmar)

Step One: Scope and objectives

What are we trying to achieve?

What is the scope of planning?

What are our timeframes?

Project managementDefinition:

The discipline of planning, organizing and managing resources to bring about the successful completion of specific project’s goals and objectives

Example:

“because it is envisaged the above will require a sustained and phased plan of action, central monitoring and accountability, it is further recommended that MoH...appoint a High-Level Midwifery Taskforce....

…Secretariat could be provided by National Reproductive Health Programme, providing additional support was available.”26 (Sherratt, White, & Chhuong, 2006)


Developing a project team

Once you are clear about the scope and objective of any planning project, you can start building the team that is responsible for completing and maintaining the work involved. This will also vary according to the size of the organization, and the nature of the tasks involved. As well as knowledge of the organization and the workforce, skills that will be useful include stakeholder management and negotiation, written and verbal communication skills, research and conceptual skills, and the technical ability to use and understand staffing, activity and finance data.

In a small organization, where the volume of information involved is relatively small, a single individual or small team may be working on any planning project. Taking staff “off-line” from their normal duties to work on the team for some of the time may provide valuable opportunities for learning and staff development. If this is the case, management support and training may need to be provided.

An alternative model is to engage those from outside the organization to develop the workforce plan. This has some advantages, in that an external “consultant” may provide a more impartial view of the nursing and midwifery workforce, its strengths and its weaknesses. This perceived impartiality may become important, particularly if significant or potentially unpopular changes are recommended. However, it can also have disadvantages. An external consultant may not have the same level of understanding of the challenges and strengths of the existing work environment and the people who work in it, or of the needs and requirements of the local community. Another risk is that staff and management within the organization, who will be called on to implement the plan, become disengaged from the process and its outcomes. If this occurs, achieving sustainable outcomes will be less likely. External technical or consultant support should therefore only be used in a planned manner where such consultants contribute to the planning process but do not lead or manage it to the exclusion of local staff.

How will the project be managed?

Day-to-day management of the planning process will ensure that the work is being completed, the necessary information obtained, the right stakeholders engaged, and that the work produced is of the required quality and type.

The project manager must understand the objectives and deliverables as they are defined, and be able to coordinate the various project activities. Where the project manager sits in the organization will influence the resources that are available. Deciding how the project will be managed also involves establishing who is accountable for delivering it, and it is important that the level of accountability matches the level of power or authority that the project manager(s) has. Workforce planning approaches are unlikely to succeed if those developing them lack the authority to implement them.8

Involving key stakeholders

A number of key stakeholders are involved in the development of any workforce plan. Workforce planning has implications for human resources policy, programme management, service delivery, and how the organization is managed, structured, and how it works with others. Key stakeholders across a wide range of areas will be affected by, and interested in, its outcomes. They will also


be able to offer unique perspectives on the issues and ways to resolve them. As time progresses, their support may be crucial to the plan being successfully implemented and opportunities for further collaboration may develop.

Who the key stakeholders are will be influenced by the scope of the planning but, in addition to senior nurses and midwives responsible for managing services, these may include representatives of health professionals and other staff that work with nurses and midwives, senior figures in the local community, staff in the organization responsible for human resources management or occupational health and safety, and staff representatives, including workplace union representatives. It may also include others either within or outside the organization who have particular skills and experience in workforce planning or contemporary nursing and midwifery practice and service delivery models.

Strong relationships and involvement will be an asset. A key project management decision is the extent to which these key stakeholders are involved in the development and maintenance of the plan. One option is to establish a formal management body such as a Management Committee or Steering Group that has a strong influence on the development of the plan, and may have a final say on its content. Alternatively, a Reference Group or Advisory Committee could provide expert input and advice, without necessarily having decision-making authority. Establishing “terms of reference” will make these parameters clear, and ensure that participants understand their role.

Alternatively, stakeholders can be invited to participate through less formal means. In any case, ensuring that they are kept informed of the project and its aims and objectives is important if their support is required to implement the outcomes. An effective communication strategy will assist in this.

What is the communication strategy?

Not everyone interested in the project will be directly involved with the project or the organization. Think about how you will ensure that all the people who need to know about the project do know about it. Strategies may include

Communication strategyDefinition:

“A communication strategy is a well-planned series of actions aimed at achieving certain objectives through the use of communication methods, techniques and approaches”17 (Mefalopulos & Kamlongera, 2004)

Examples:

Policy documents and discussion papers

Brochures and newsletters

Staff meetings

Public discussions

Appearances on radio or other mass media

Posters or advertising

Step 2: Establish project management

Who are the sponsors?

Who constitutes the planning team?

How will the project be managed?

Who are your key stakeholders, and how will you involve them?

What is your communication strategy?


Regular newsletters and updates, which can be made available to the public or pinned •up on notice boards.

Regular meetings – these can be a particularly good way for staff and the local community •to learn about the project, share their ideas and raise any concerns. Meetings are a particularly good way to share information with members of the community who prefer verbal rather than written communication. Project reports, updating key stakeholders on the progress of the project. These are a good way to communicate to other senior members of the organization, fund holders and sponsors.

Step 3: Assess the environmentWorkforce planning does not occur in isolation. It is part of a complex network of interrelating factors, all of which impact on planning decisions. These range from broad policy concerns to the concerns and challenges facing local communities. It aims to identify all those factors, both internal and external, which will impact on the way that nursing and midwifery services will be delivered in the short and long term.

Service planning

It is essential that workforce planning occurs within the context of a sound understanding of the services that you are trying to deliver. Workforce plans should be able to accommodate the changes in staffing that are brought about by changes to service delivery, as well as cater for the needs arising from staff turnover. “Service planning and workforce planning are components of an integrated, iterative process. The service plan articulates the goals that workforce plans need to implement.”

If your agency or organization has prepared a service plan, it will be a vital reference and provide key information that you will need to inform your workforce planning process.

However, in many cases, service plans are either not available, or may not provide enough detail. If that is the case, further information is provided in Step 5 on how you can use your knowledge to estimate future needs. In the meantime, talk to others in your organization and make sure you know as much as possible about plans for the future. While it is beyond the scope of this paper to outline service planning in detail, a number of resources are publicly available which will help you to start the process.18

Key elements to look for in a service plan for nursing and midwifery include

The service “catchment”: the area to which you provide services and its key •characteristics

Demographics and epidemiology: the population, its distribution and characteristics, •and how it is anticipated to change over time. Birthrates and burden of disease should be considered. This should include seasonal changes, where relevant.

Service planningDefinition:

“The process of ‘Service planning’ defines the core services to be delivered to the community, in conjunction with the necessary ancillary or support services.”

“Service planning is when you develop and describe a vision of what you want health and social services to be like.”


Current services, and any new services that are planned•

Service demands and how they will change and grow over time•

Preferred models for delivering services, taking into consideration current and future •service demand and the resources and capacity available to deliver them

Any likely changes that will affect services in the future such as anticipated changes in •health status, technology

Relevant links to other service providers who provide similar and related services•

The number and distribution of service delivery locations•

Budgetary constraints and considerations.•

The better you are able to understand the likely future for your service, the better you will be able to plan for the workforce that will be required to deliver those services.

Policy context

A great deal of activity has been undertaken in SEAR over the past few years in order to support improvements in workforce planning for health and human resources. Many countries now have some established policy framework that sets out key directions for the development of workforce planning. While not all the elements in these national-level plans will be of direct relevance in local planning circumstances, they provide a useful framework to guide activities. Ensuring that you are familiar and consistent with these key directions in your own work will maximize your chances of success. Some examples of key documents providing an overview of health and human resource policies in each of the countries in the Region are listed in Figure 5.

Figure 4: Service planning and workforce planning – an integrated approach


Figure 5: Examples of national health and human resources for health (HRH) policy and planning documents, SEAR countries

Province/state/regional policy and planning

Subnational strategic plans, particularly at the state or province level in larger and federated countries, can also have a major impact on workforce needs. For example, building a new infrastructure, or an industry or business starting up or closing down can have a significant impact on both the nature and the demographics of the local health of the population. Developments such as these can present both opportunities and risks. Local and regional governments and other organizations may be able to assist you with collecting data and information.


Regulation and legislation

It is important to understand the requirements and parameters of any regulation and legislation that will impact on the practice and employment of nurses and midwives. These may apply to a number of different areas including terms and conditions of employment, scope of practice, and occupational health and safety requirements. This will ensure that

planning-based assumptions and changes are developed and implemented within appropriate legal parameters.

Full-time equivalent (FTE)Definition:

“the total number of hours worked by the cohort of nurses, divided by the average number of hours worked by a full-time nurse in total.”

Example 1 (small cohort)

The standard full-time working week for nurses nationally is 40 hours. A health centre employs a total of 5 nurses as follows:

2x 40 hours per week (full-time) 2x25 hours per week 1x10 hours per week

This equates to a full-time equivalent of 3.25 ((40+40+25+25+10)/40).

Example 2 (large cohort)

In this example, average, rather than actual working hours, are used. This can be useful when developing estimates for large workforces where adding each individual’s working hours is impractical.

The standard full-time working week for nurses nationally is 40 hours. A hospital employs 600 nurses, including many who work part-time. The average weekly working hours across the 600 nurses is 32 hours per week.

The full-time equivalent for this hospital is 480. ((32x6000/40)

Step3: Assess the environment

What services do you deliver, and will you deliver in future?

What are the relevant polices?

What laws and regulations should you be aware of?

Step 4: Describe workforce capacity and supply

Understanding your workforce now

It is important to understand the nature of the nursing and midwifery workforce, its composition and distribution. Ideally, you should be able to answer all these key questions (in practice, this may not be feasible):

How many nurses and midwives are there •in the population?

How many nurses and midwives are currently •in employment in nursing/midwifery?

What is the distribution of nurses and •midwives across different service locations?

What proportion of nurse and midwives •work part time?

What are the total hours of nursing and •midwifery services provided (as opposed to the number of individuals working)?

What is the demographic profile of the •current workforce (in particular, age profile and gender)?

What are their qualifications, skills and •competencies?

How many nursing and midwifery positions •are available in the organization?

How many of these positions are currently •vacant (and what have been the yearly trends in vacancies)?


How many nurses and midwives have left the organization (numbers leaving, by •month or year)?

How many nurses and midwives joined the organization (numbers joining, by month •or year)?

As discussed earlier, the overall purpose of the workforce planning process is to make staff with the right skills available in the right places at the right time. Effective planning requires accurate data; the more complete and up to date the available data, the more accurate the planning input. It is therefore important that the data collection process “makes explicit the need for midwifery services to be provided by competent midwives or others with midwifery skills”.28

Both the number of staff available and the number required are usually converted into both a headcount and a full-time equivalent (FTE). Calculating the FTE provides a standard measure – the number of actual individuals required will vary according to the number of hours each of those employees works.

Depending on the scope of your project (see Step 1) , it may also be useful to collect the same information for those parts of the workforce that work closely with nurses and midwifes in delivering key services, such as nursing auxiliaries, community-based health workers, or local birthing attendants. This is particularly recommended if you are highly dependent on these staff for the delivery of key services, and is particularly important when examining policy issues related to skill mix and task shifting. For example, if you are seeking to expand the coverage for the population of qualified midwives, it will be important to understand which workers are currently providing those services, and how that might change over time.

Workforce turnover: balancing attrition and supply

“Turnover” is a term which is used to describe the number of employees joining and leaving an organization in any given period of time. There are different ways of measuring turnover but the most common is to calculate a turnover rate based on the percentage of staff who left the organization in a twelve-month period. As noted by the Organization for Economic Development and Co-operation (OECD), it is “the sum of net employment changes … expressed as a percentage of total employment”.29 It excludes “job vacancies which remain unfilled and jobs that begin and end over the interval of observation, which is most often one year”.29

Understanding turnover in the organization will allow you to estimate how many new nurses and midwives you will need in order to maintain your current staffing levels. If measured across an organization or system, it can also help you identify areas or regions that report higher or lower rates of turnover. If you find that you need to increase your staffing levels, this will be in addition to the new nurses that are needed just to replace those that are lost each year.

TurnoverDefinition:

The number of employees joining and leaving an organization in any given period of time, usually expressed as a percentage of staff who left the organization in a 12-month period.

Example:

A unit with 100 staff that reports 10 have left in the last twelve months would have a turnover rate of 10% (10/100).


Strengths, weaknesses and tensions

In addition to collecting quantifiable data about the workforce, it is also important to understand some of the issues that reflect on the nature of the workforce and its well-being. These can be important factors in retention of the workforce. As well, you need to identify the strengths that can be developed in the future. Understanding the “employee climate” will also help you to identify and prepare for challenges that you may encounter when seeking to implement strategies and changes. Key questions may be

Is the morale of nurses and midwives good, and the culture positive?•

What are the strengths of emerging leaders in nursing and midwifery?•

Are we effectively investing in and developing our human resources?•

Do nurses and midwives feel safe in their working environment?•

What challenges are the staff facing at work and in the local community?•

Some of the data that can be collected about your workforce, such as turnover and retention, and rates of absenteeism will give you some indicators to the above questions.

Accessing data

The availability of the kind of workforce data discussed above will vary according to the nature of your service, its size, and the extent to which it has a dedicated personnel management function, and human resource information system (HRIS). Some organizations may be able to provide reports such as these routinely, using computerized HRIS databases which record information about employees as part of the personnel management and data function.

If the data are not held centrally, you may consider using a staff survey to collect it, or ask managers and supervisors to provide information about their teams. If you work in an organization with a relatively small number of people, this will be a relatively easy exercise. If larger numbers are involved, you may need to enlist the help of managers and others in the organization to share the task.

The pitfalls of poor data

In late 2008, it was reported that a review of employee records at the Ministry of Health and Social Welfare, Tanzania, had identified that 1413 workers on the payroll did not really exist.

This provides a stark example of how poor-quality or out-of-date data can distort workforce planning and assessment. Do your best to ensure that the data you are using are timely and accurate. The estimates you make can only be as good as the data you use.30

When collecting data, be practical, pragmatic and brief: aim for a “minimum dataset”. You should also consider if it is sensible to set up a routine system for data gathering rather than a one-off exercise.

Start early to minimize project delays. Collecting and collating data takes time, and •this crucial step should be under way as quickly as possible if it is not to hold up the project.


Wherever possible, use existing data sources, •rather than creating new ones.

Do not collect data unless you are clear that •they are required.

Do not collect data that you do not have the •resources to collate and analyse.

Use tools that are simple to develop and •use. If your service is fully networked with computers, a simple online survey could be developed.

Use and share information responsibility, •and in accordance with relevant protocols, regulations or legislation.

Forecasting supply

It is often difficult for a small organization to forecast the likely supply of new staff. However, there may be some key elements that you can identify, which will be a valuable addition to your assessment.

For example, if your service has a number of nursing students who undertake practical placements with your organization, experience will tell you how many of these students then go on to be offered or accept jobs in your organization. You can work with the colleges, universities and other training institutes that are sources of new supply of staff to ascertain what future patterns of supply will look like.

In addition, there may be elements of supply that you directly control. For example, if your organization conducts an annual training programme which teaches basic midwifery skills to health workers, you can monitor how many of those who attend usually successfully complete the course and go on to accept jobs in this field.

Step 5: Estimate future needsThe objective of this step is to try and determine how many nurses and midwives will be needed in the future in order to deliver the health care determined by service objectives. Any key service changes, as identified in the environmental scan (see Step 2) will need to be factored into this step.

You will also need to consider the strengths and weaknesses of your current workforce, and take into consideration what will be required to balance the natural turnover and attrition of workers from the service, in addition to what might be needed to fill service provision gaps or achieve service expansion.

The pitfalls of poor data

In late 2008, it was reported that a review of employee records at the Ministry of Health and Social Welfare, Tanzania, had identified that 1413 workers on the payroll did not really exist.

This provides a stark example of how poor-quality or out-of-date data can distort workforce planning and assessment. Do your best to ensure that the data you are using are timely and accurate. The estimates you make can only be as good as the data you use. (Samwel 2008)

Step 4: Describe workforce capacity

What are the characteristics of the current workforce?

How many people are leaving and joining?

What vacancies are there, and where?

What data do I need, and how will I get it?


It is important to remember that these forecasts are only estimates, and the longer the time-frame involved, the less accurate your forecast is likely to be.30 However, it is worthwhile making them as accurate as possible. A gross overestimate of the number of staff required in the future will result in establishing objectives that will be unpractical and unachievable, as well as wasted expenditure. Equally, if future staffing requirements are underestimated, this could lead to shortages of staff, disruption to services, and a missed opportunity to implement strategies that would prevent or ameliorate future shortages.

It is also important to choose a method that is appropriate to the size of the health service and that can be used effectively with the resources, knowledge, data and skills that you have available. In the process of estimating future needs, it is also important to combine formal and quantitative approaches in consultation with relevant stakeholders.

Projection models and approaches

A number of approaches and techniques have been identified to assist with developing an accurate workforce projection. The appropriate method to use is dependent on factors such as

the size of the workforce;•

the level of services planning which has already been undertaken;•

the level of variation in skills mix which is needed; and•

the level at which the workforce has been described, quantified and documented •previously.

Qualitative approaches

Discussions with others will be a key source of information in ensuring that your workforce estimates are as accurate and realistic as possible. In addition to consulting with the key stakeholder groups that you have already established, there are a number of ways you can obtain this information. This includes

interviews with key informants including staff, managers and experts•

focus groups to obtain anecdotal reports •

“brainstorming sessions” to identify forces that are likely to bring about change•

“Delphi technique” discussions in which experts are drawn together to debate and •discuss the likely future directions and their impacts and implications.32

Quantitative models

A number of online resources are available from across the world which provide a detailed description of the various approaches to forecasting that are available, by a diverse range of organizations including the Australian Workforce Advisory Committee,4 the Irish report on nursing and midwifery planning, which distinguishes between methods used to estimate future workforce requirements – health needs, service targets, health demands and workforce/population ratios – and methods used to predict future demand for services – per cent adjustments, twelve-month moving average, trend line and seasonalized forecast.20


The Capacity Project has prepared a useful overview of projection models, which outlines the advantages and disadvantages of each, and the assumptions that underlie them.33 It describes

needs-based approaches, which estimate future need based on the projected health •services needs of the current population, incorporating professional norms and expertise in order to discover the most cost-effective method of meeting health-care needs

utilization-based approaches, which project future health services requirements based •on present health service utilization. This approach may incorporate projected trends in the current workforce, such as demographics, turnover and attrition rates.

health workforce-to-population ratios, which uses estimates of the current and •desired future ratio of nurses and midwives-to-population to develop estimates of the projected need. This is then compared with the projected future supply to identify the gap.

service target-based approaches, which set targets for specific health-care services, •based on health worker supply or demand. These targets are then translated into staffing requirements for personnel and productivity norms for health-care facilities.

adjusted service target-based approaches, which the authors suggest are useful for •specific health intervention programmes. In this approach, targets are established based on priority health services needs (based on demographics, expert option and analysis of population health indicators). Specific interventions addressing priority needs are identified and functional job analyses used to determine the health worker skills required.

facilities-based approaches, which take the health facilities as a starting point, and •develop targets based on accepted staffing standards in each type of facility.

A further technique suggested by the Australian Health Workforce Advisory Committee is a models of care (or multidisciplinary) approach.

Ideally a “models of care” approach to assessing workforce requirements is based on the most effective and efficient way of delivering health services based on a model of care determined to provide the best outcomes for patients in the most efficient manner (outcomes based). First, the appropriate model(s) of care needs to be defined. Importantly, this includes defining the appropriate workforce mix and level of supply. Agreement is necessary on the preferred model(s) of care. This approach to planning should facilitate consideration of future workforce supply in a more integrated manner across all health occupations involved in the delivery of a particular model or stream of care.4

This approach has the advantage of providing a means to balance the needs of the population, and the desired outcome in terms of services provided, with a practical assessment of the available resources. It also incorporates the process and outcome of service reform efforts into workforce forecasting, and avoids the risks of assuming that things will be done in the future the same

Step 5: Estimate future needs

What is our existing shortfall?

What additional staff do we need to implement our service plan?

What is the best approach to forecasting for our service to use?


way that they have been done in the past. This has been identified as a recurring flaw in many workforce planning efforts.8

As Mc Quide et al. note, “choosing a projection approach or forecasting method requires deliberate consideration since the type of model used can have a significant effect on the resulting outcomes and recommendations”.33

Step 6: Gap analysis Identifying the “gap” between the number of nurses and midwives you have and the number of nurses and midwives that you need is a key step. Through carefully analysing the information you have been able to collect, you should be able to identify:

realistic assumptions on the overall number of nurses and midwives needed in the •future

those areas (geographical or by service/specialty) where staff shortages are currently •most evident

those areas where shortages are most likely to be evident in the future•

what types of staff or skill sets are most urgently needed to enable care to be •delivered.

Figure 6 provides a simple example of how this analysis might be summarized. This example describes a health service which comprises an acute health facility in a small town, with two additional, smaller facilities providing limited emergency response and community-based midwifery care. The service has included its estimates of how many of its staff will leave or retire, and how many they expect to supply through training and recruitment.

A number of key workforce issues are immediately apparent on using a tool such as this:

An additional six nurses will be required during year one in order to fill vacancies and •replace staff due to retire or likely to leave.

There are unfilled positions for both nurses and midwives across all locations.•

Despite there being fewer midwifery positions, the vacancy rate for the positions is •expected to worsen over time.

There are critical shortages at Location 2.•

A high number of nursing staff are due to retire over the next three years.•

Even though this health service has successfully secured an annual supply of three •nurses, and is training additional birthing attendants, this supply is not sufficient to compensate for the number of staff leaving the service.

The same tool can be used as a means to project outcomes of proposed strategies. For example, if a range of retention strategies were introduced targeting nursing assistants so that annual resignations fell from six to three at Location 1, the model would show a gradual reduction in vacancies, rather than a growing shortage.


Step 7: Strategy development

Prioritize

In developing specific strategies to address the gaps identified in the previous stage, it is important to identify the gaps that are most critical to address in order to be able to deliver services.

Issues to be considered include the following:

What are the most critical workforce gaps in terms of continued delivery of health •services to the community?

What gaps result from short-term operational issues?•

What gaps stem from longer-term or structural problems?•

What are the risks associated with the identified workforce gaps?•

Which risks are acceptable? Which are not?• 32

Figure 6: Simple gap analysis tool

Nurses MidwivesNursingAssistants Nurses Midwives

NursingAssistants Nurses Midwives

NursingAssistants

LOCATION ONEFunded Positions 10 5 25 10 6 25 10 6 25(in post) (7) (4) (19) (4) (4) (15) (1) (2) (13)

Plus:Vacant positions 3 1 6 6 2 10 9 4 12Retirement 3 2 3 2 3 1 2Resignation 3 1 6 3 1 6 3 1 6New Positions 1

MinusNew recruits 3 3 3Training outcomes 4 6 8

Additional staff required 6 2 10 9 4 12 12 6 12

LOCATION TWOFunded Positions 1 1 1 1 2 1 1 2 1(in post) (0) (0) (1) (1) (1) (0) (0) (1) (1)

Plus:Vacancies 1 1 1 1 1 1 0RetirementResignation 1New Positions 1

MinusNew recruits 1 1 1Training outcomes


LOCATION THREEFunded Positions 1 0 4 1 1 5 2 2 5(in post) (1) (0) (3) (1) (1) (5) (2) (1) (5)

Vacancies 1 1Retirement 1 2Resignation 1 1 1New Positions 1 1 1 1

New recruits 0Training outcomes


Total Funded positions 12 6 30 12 9 31 13 10 31Total additional staff required 6 3 13 10 6 13 15 9 15

Year ThreeYear One Year Two


In the example discussed in Step 6, for example, the data presented suggest that urgent action is needed to ensure continued service delivery at Location 3, where consultations have shown that the workload and stress of being the sole health-care provider in the location is a major factor in the high turnover of birthing attendants. This has meant that there has been no staff at all for extended periods, placing mothers and their babies at risk. Successfully filling the other positions at this site will improve the quality of care of the local community. It will also result in a more positive and supportive working environment for the birthing attendant, and the likelihood that the trained birthing attendant will stay in their position, becoming increasingly more skilled and experienced and reducing the costs (such as training and recruitment costs) associated with high turnover.

All health services operate with limited access to resources, and it is unlikely that every staffing requirement will be addressed at once. To do so would be neither practical nor possible. It is therefore important to ensure that efforts are directed to the most critical needs. The process of workforce planning is ongoing and iterative; over time, different issues will emerge as others are solved.

Approaches to strategy development

Understanding the problem

The key to developing effective workforce planning strategies is to develop a sound understanding of the problem. The gap analysis identified in the previous step helps you identify where and what the problem is, but not necessarily why it has arisen. Once the root of the problem is identified, the kinds of strategies that might be most useful to pursue can be identified.

Figure 7: Balancing requirements and supplies


In many cases, the research and consultation that you have already conducted as part of the workforce planning process will suggest possible avenues that can be pursued.

Guiding principles for these strategic actions is that they should be practical, deliverable and have tangible, identifiable outcomes. The strategies that are developed should not just address the immediate problem, but contribute to the overall achievement of the long-term development of a sustainable workforce. They must also be consistent with the organization’s goals, and with each other, so that each one contributes to a shared objective of a sustainable approach to service delivery.

Strategic directions

Scaling up

The term “scaling up” refers to the wide range of strategies and interventions that can be used in order to increase the capacity of the health workforce. This can be achieved by increasing the number of providers available; improving the productivity of health workers and making better use of their skills; improving their distribution; and improving their effectiveness through better techniques and training.33

The Islamabad Declaration19 sets out key principles for scaling up nursing and midwifery capacity, including the need for a range of strategies to be considered such as workforce planning, skill mix and career frameworks , the need for high-level leadership and commitment, the importance of ongoing data collection and monitoring, and short-term crisis responses which contribute to longer term goals. These principles are reproduced in full in Appendix 2.

Similarly, the Global Health Workforce Alliance Task Force for Scaling Up the Education and Training of Health Workers (2008) identifies three key areas for successful scaling up efforts – political commitment and good governance, workforce planning and an enabling environment.

In his literature review on the topic, Buchan notes two important considerations when “scaling up” the health workforce:33

“Firstly there is a need to consider ‘contingency’ – to ensure that there is a ‘fit’ between the interventions and the characteristics, context and priorities of the organisation in which the

Scaling upDefinition

“expanding and improving an intervention, a programme or services with a view to meeting some desirable target more rapidly. It implies purposeful efforts to accelerate the pace of action and progress towards a certain goal” (Dussault et al. 2009 p.7)

Example

Since 2001, Bangladesh has been developing a training programme for community-based skilled birthing attendants (CSBAs), based on existing community health workers, the family welfare assistant and the female health assistant.

Supervisors of the CSBA – a cadre called family welfare visitors – also receive training in midwifery focused on life-saving skills as well as supportive supervision. As part of this supervision, the CSBA keeps a log book and is encouraged to reflect on their own practice.

These initiatives are part of a broader supervision system being developed to encompass other aspects of maternal healthcare provision.

Source: UNFPA-ICM (UNFPA-ICM n.d.)


interventions are to be applied. Secondly, so-called ‘bundles’ of linked and coordinated interventions are more likely to achieve sustained improvements in organisational performance than single or uncoordinated interventions.”

As noted by Dussault et al., scaling up can be achieved through augmenting the numbers of workers available, improving the efficiency or productivity of the existing workers, or improving the “geographical and institutional coverage” and effectiveness.

Key strategies employed when seeking to increase the number of available health workers are detailed in that report, and include

Augmenting the production of new workers,•

Improving retention rates, e.g. by providing better terms and conditions including •wages, financial and non-financial incentives, or implementing more flexible models of employment, and improving the working environment,

Harnessing unemployed, inactive or retired workers, and•

“Importing” health workers.•

‘Task shifting” can also be employed to improve the effectiveness and efficiency (Dussault et al 2009).35 As noted by Dr Margaret Chan, Director-General of WHO, “the task shifting approach represents a return to the core principles that are accessible, equitable and of good quality”.36

Implementing staff development and education and training strategies in order to increase the skills and abilities of the existing workforce is also an important aspect of improving workforce effectiveness. This can include strategies which aim to ensure that nurses and midwives have the appropriate skills and competencies to perform their duties. Education and training is also a vital part of developing new supplies of workers to perform existing roles, to develop new roles to assist nurses and midwives to manage their workloads, and ensure that their skills are put to the best use.

Developing the right mix of workers and skills ensures that nurses and midwives are able to apply their skills where the most benefit will be gained.

Since health care involves a continuum of role, functions and skills that should complement one another, it is essential that different categories of health workers are represented in the health team in the right proportions. In many countries there is still inefficient and inappropriate use of human resources with noticeable over-representation and under-representation of certain categories such as nurses, midwives and paramedical personnel in such teams.6

Examples of poor use of staff and their skills include highly trained clinical staff spending large amounts of time on clerical or administrative duties that could be more effectively performed by a clerk, or with computer support.33

A range of strategies is being developed and implemented which seek to specifically address the issue of recruitment and retention of workers in rural areas. Professional support, safety, access to personal and professional development opportunities have all been identified as key issues.


Several incentive strategies have been employed. In addition, many countries have pursued the recruitment and training of local people to improve availability of vital health skills. This strategy is being pursued as a means to increase the likelihood of retention, while it provides valuable employment opportunities for local workers.37,38

Reviewing administrative and management processes

There are a range of managerial and administrative processes and practices which can have a significant influence on the ability to fill positions. It is important to consider whether these elements might be impacting on your workforce issues. For example,

Do staff have access to the equipment and materials they need to work? Are consumable •products (e.g. dressings) ordered, obtained and delivered in a timely manner?

Do the administrative processes required to authorize the establishment of new •positions or hiring of new staff result in excessive delays? Does this contribute to positions remaining unfilled?

Are payroll functions effective and efficient? Do staff feel confident they will be fairly •rewarded for their work?

Do all staff have appropriate supervision?•

Factors such as these may not immediately present themselves as being strategies to address workforce issues. However, if they emerge as significant causes of frustration for staff and contribute to staff attrition, relatively low-cost solutions to improving the work environment may soon present themselves.

Managing demand

In addition to strategies that seek to scale up the workforce, strategies that manage demand may also be considered. These kinds of strategies are unlikely to be useful in resolving short-term issues, but can be extremely effective in the long term.

Actively promoting and supporting public health measures such as good sanitation, nutrition and access to clean drinking water, and basic public education about preventable transmissible diseases are a good long-term investment for health services facing high needs and long-term workforce challenges. Such measures provide a good example of the way in which intervening at the public health and primary care end of the care continuum can help prevent the development of avoidable disease and the demand that it places on local health services.

Refining and costing strategies

The range of strategies that present themselves should now be evaluated against the priority issues that you set out to address. You should now review the strategies to see which of these should be pursued and implemented. In addition to the urgency of the issue that needs to be addressed, this decision should also consider

The degree of difficulty involved in its implementation•

The estimated time-lag between implementation and outcome•


The likelihood of success•

The costs associated with its implementation, and •

The benefits to be gained through its success.•

Strategies that are complex and difficult may still be worth pursuing vigorously if the evidence suggests that these will be the most effective way to develop a long-term, sustainable solution. By the same token, a strategy which may have relatively small gains, but can be quickly and easily implemented, may also be worthwhile.

The support – financial and otherwise – of key stakeholders, particularly the organization’s leadership team, is crucial. Developing a clear description of each strategy, its objectives, its costs and benefits, the evidence base that supports its development, as well as key implementation issues will help secure this support, and ensure that all involved are aware of what will be required to make it work.

Step 8: Implement

Project planning

Progressing the strategies into the implementation stage will require a detailed workplan. As with the development of the workforce development plan itself, planning is a very important part of ensuring that the changes that you make will be implemented smoothly and are sustainable. Your project planning should include

Identifying project leaders•

Mapping out the steps required in order to implement the project•

Identifying any critical dates, and establishing target dates for key project stages to •enable you to monitor your project

Planning a strategy for consultation with, and providing information to, those in the •organization who may be affected

Identifying key outcomes•

Project costs, in terms of both the staffing resources and time needed to implement •the project, as well as any direct financial costs, such as the costs associated with creating new positions or training programmes.

If you are proposing significant changes, you may also need to plan to ensure that there are no operational impacts. For example, if you are planning to “task-shift” between staff, you may want to include measures of additional supervision or mentoring during the transition period to ensure that there is no reduction in the quality of care while people are getting used to their new roles.

Step 7: Strategy development

Why have the gaps in service arisen?

How have others solved similar problems?

Who do I need to discuss ideas with?

Are my strategies realistic and implementable?


Authorization and support

The project plans that you develop will pay an important role in ensuring that you secure the support – including financial support – and permission that you need to proceed. During the implementation of any process of change, there is likely to be some disruption. You may encounter difficult and unforeseen problems that will need cooperation and goodwill to successfully solve. There may be some that disagree with the directions that are being taken, or feel personally threatened by the changes.

The implementation could also result in increased workload for some or all involved. This can be very challenging in an environment where staff are already working very hard to keep the current service running . All those involved therefore need to be fully committed to the project, and aware of its costs and benefits. Securing formal agreement from the relevant management group, such as a written “sign-off” of the project plans or formal agreement from management committees or boards may form part of this process. Conversely, there may be smaller changes that it is within your own authority to implement locally.

Step 9: Monitor and evaluateMonitoring and evaluation of the workforce plan should be an integral part of its implementation. This is the vital step that lets you know whether you are achieving your goals, and helps you to determine what you need to do next to ensure that you have a sustainable supply of staff to continue to deliver nursing and midwifery services for your community in the future.

Your workforce plans should be reviewed at least annually – more frequently if there are significant changes or events which impact on your workforce and what you are trying to achieve. As time passes, you will be able to refine the projections that you made about the future, and adjust for the changes that have occurred in the meantime – including the outcomes of your own efforts.

The workplan review process involves

Reviewing performance measurement information, such as:•

Whether project timelines have been met –

Performance against key indicators of success such as turnover rates –

The views of managers, staff and service users about the impact of the changes –

The State Services Authority of Victoria, Australia, in its guide to workforce planning, has outlined key questions to consider when preparing to implement and manage change:

What is the most seamless and effective •way to implement the changes?What barriers or issues may be present or •potentially arise at different stages?How could the workforce react? What •are their key motivators?What is the level of change management •skills among the management?What is the ultimate aim of these •changes?

(State Services Authority 2006) [ref 36]

Step 8: Implement

What is the simplest and most effective way to implement the strategies?

Do we have the support we need to proceed?

What do we need to do to manage the change process?


In the light of this evidence, assess which strategies are working and which are not•

Adjust the plans and strategies as required to improve their effectiveness •

Consider any new workforce issue or changes that have emerged, and whether these •necessitate changes or additions to the plan.

As noted in the United Kingdom’s (UK’s) Six steps methodology to workforce planning,39 the process of evaluating the plan is a learning process, as well as an opportunity to update the plan. The process of review will help build the skills and capacity of the organization to effectively plan for the workforce into the future. This methodology warns against “throwing away the old plan and starting from scratch”, as this will reduce the learning opportunities. Instead, it suggests

“Do go through every step of the planning process again, even if you have an •inclination where the problem lies. You can learn from what went right as well as what went wrong.

Do make sure that you have kept all the assumptions, data, etc. from the original •planning and check and update them.

Re-engage with all the stakeholders and involve them in the process to make sure they are still signed up to the goals and assumptions.”39

Successful workforce planningThe following list has been drawn from a range of sources including The nursing and midwifery workforce: final report of the Steering Group: towards workforce planning (Department of Health and Children 2002),20 Collection and analysis of human resources for health (HRH) strategic plans,8 Health human resources planning,40 and Rural health workforce planning guidelines.5

Be practical

While it is important to be ambitious in the outcomes you are trying to achieve for staff, and services to the local population, the strategies that you develop must be practical and reasonable in order to succeed. Plans which are unaffordable, overly optimistic in their intended outcomes, or unreasonable in their expectation of how quickly and easily change can be implemented will be less likely to succeed.

Be appropriate

Use an approach and methodology that is applicable to your country, local circumstances, and the skills and tools that you have at your disposal. Be realistic about what you can achieve within the scope of your resources and the time available.

Step Nine: Monitor and evaluate

Are we meeting our key targets and objectives?

Are our aims and assumptions still valid?

What have we learned?

What do we need to do to further improve?


Integrate with other planning processes

Service plans, financial management plans, and training and development plans are all relevant to, and should be aligned or linked with, workforce planning processes and strategies. Ensure that your workforce planning is consistent with and complementary to other workforce planning processes.

Consider your whole workforce

The effective delivery of health services involves careful consideration of the range of skills at your disposal, and how these can be most effectively and efficiently used to deliver care. This becomes even more important when key skills are in short supply. Think about how different cadres work together, and how they can work together more effectively.

Consider distribution

Workforce planning is not just about getting enough staff; it is also about getting the right mix of staff to the right locations, so that services can be equitably provided to all members of the local community.

Think about process as well as product

It has been documented that the need to involve others in workforce planning is an important part of developing effective and practical strategies, and ensuring that they are implemented. One way to achieve this is to carefully manage the process of planning, as well as the product. Remember that the plan itself is only a tool to help you achieve health outcomes.

Be creative

Do not assume that the way things are done now is the way that they must continue to be done. The solution to filling gaps between the available workforce and the projected workforce needs may be to use staff differently, rather than find more staff.

Build on your strengths

Your greatest asset is the staff you already have. Ensure that strategies to resolve emerging workforce shortages include those aiming to retain and develop these staff, and not just on attracting more. Consider their quality, motivation, utilization and development.

Review, revise, revisit

Remember that your workforce projections are only estimates. The changing nature of the environment means that they will never be 100% correct, and that strategies that were the most worthwhile a year ago may not remain the best in two years’ time. Do not expect to solve every problem at once, and remember that workforce planning is an ongoing, iterative process, not a one-off project.


Appendix 1

Excerpt from Regional strategic plan for health workforce development in the

South-East Asia Region7

Vision, mission, goals and strategic objectives

Vision

The overall vision of WHO in this area is for Member countries of the SEA Region to achieve optimum health outcomes by ensuring equitable access to effective health services through a balanced distribution of a sufficient, competent, passionate and highly motivated health workforce.

Mission

Cognizant of its role and responsibilities, WHO pledges to support Member countries of the SEA Region to strengthen their capacity in planning, training, deployment and managing the health workforce to meet the increasing health demands.

Goal

To exert a coordinated effort to assist Member countries in human resource development for health with a view to develop a health workforce that will be responsive to the health needs of the population.

Strategic objectives

The strategic objectives are:

(a) To ensure that health workforce planning and development based on sound evidence continue to be integral components of national development plans of Member countries;

(b) To support Member countries to scale-up production of a high-quality health workforce in a changing service environment;

(c) To strengthen the stewardship and management of health systems to ensure the delivery of cost-effective services through a highly motivated workforce, and

(d) To provide a platform where Member countries of the Region can share their experiences while assisting each other in health workforce development.


Key result areas

The strategic objectives are organized around three key result areas which provide the foundation for the development of an effective health workforce in the Region. These are:

(a) Need-based health workforce planning: Health workforce planning is based on sound evidence that captures the changing health needs of the population in the sociodemographic and sociocultural context of the population.

(b) Need-based health workforce development: Health workforce development is based on technological advancement, changing health needs of the population and on the increasing expectations of consumers.

(c) Stewardship and management of the health workforce: Sound stewardship and effective management of the health workforce, local recruitment, training and hometown placement, supervision and effective incentive systems will lead to a high level of motivation among health-care workers, thereby leading to their retention and committed performance.

Guiding principles(a) At all stages of the planning process, it is recommended that decisions should be

based on sound evidence, whenever available. This highlights the need to build up and strengthen national institutional capacity to generate evidence and translate it into sound policies, programmes and practices. Health workforce planning must comprise a comprehensive approach towards public and private sector health workforce needs.

(b) The development mechanism will help minimize the geographical imbalances in health workforce distribution, and make the distribution equitable.

(c) The need to have adequate human resources to provide services targeted at the poor and the underprivileged will be placed at the centre of development plans as the poor shoulder most of the burden of diseases. They are also the key stakeholders in achieving the health-related MDGs.

(d) Member countries will be urged to consider the sociocultural context, taking into account the local political and economic circumstances.

(e) Utmost care will be taken to minimize gender imbalances during all stages of the planning and implementation process.

(f) Occupational and professional advancement of health-care workers will be enhanced by providing them with healthy workplaces.


Appendix 2

Principles for scaling up nursing and midwifery capacity, Islamabad Declaration,

200720

Scaling up nursing and midwifery capacity encompasses a range of strategies that address workforce planning, education, skill-mix, maximum utilization of roles, career frameworks, work environments and regulatory frameworks to ensure efficient, effective and safe health systems.

High-level political leadership and commitment, a multisectoral approach, significant financial investment in education and employment expansion, and active participation of leaders in nursing and midwifery are required to enhance scaling up of the nursing and midwifery workforce.

Each country must establish policies and practices to ensure self-sufficiency in workforce production within the limits of its own resources.

Nursing and midwifery capacity development requires ongoing data collection and their integration into health information systems, as well as regular and rigorous monitoring and evaluation to enhance evidence-based decision-making.

Rapid scaling-up measures may be appropriate in country-specific crisis situations; such measures should contribute to longer-term sustainable development of the nursing and midwifery workforce.


Appendix 3

Examples of workforce planning guidelines, processes and resources

Publications

The following list represents a sample of the workforce planning guidelines that are freely available.

The NHS’s • Six steps methodology to integrated workforce planning includes both written guidelines and online resources (http://www.healthcareworkforce.nhs.uk/resources/latest_resources/six_steps_refresh.html). This is targeted at the United Kingdom’s National Health Service (NHS) to assist them in their workforce planning across their health workforce. (Workforce Projects Team, Skills for Health. Six steps methodology to integrated workforce planning. Manchester, Skills for Health, 2008.)

Rural and regional workforce planning guidelines• provide a simple, step-by-step approach to workforce planning, intended to assist rural health services in Victoria, Australia to conduct workforce planning in a rural context. (Rural and Regional Health Services Branch. Rural health workforce planning guidelines. Melbourne, Rural and Regional Health Services Branch, Rural and Regional Health and Aged care Services Division, Victorian Department of Human Services, 2006.)

The nursing and midwifery workforce: final report of the Steering Group: towards •workforce planning. This report from Ireland includes a comprehensive overview of the process, methodology and outcomes of the workforce planning process used. (Department of Health and Children. The nursing and midwifery resource: final report of the Steering Group: towards workforce planning. Dublin, Department of Health and Children, 2002.)

Workforce planning toolkit: a guide to workforce planning in small to medium sized •Victorian public sector organizations. These guidelines from Australia provide a generic (rather than HRH) approach to workforce planning, but describe a broadly applicable approach. (State Services Authority. Workforce planning toolkit: a guide for workforce planning in small to medium sized victorian public sector organisations. Melbourne, State Services Authority, 2006.)

Workforce planning guide• . (Texas, State Auditor’s Office, 2006)


Quantitative tools

HRIS strengthening implementation toolkit, Capacity Project/USAID/IntraHealth International, 2009. http://www.capacityproject.org/hris/hris-toolkit/index.html (accessed on 09 November 2009).

NHS Nurse workforce planning tool. (downloadable excel spreadsheet) NHS, England. http://www.healthcareworkforce.nhs.uk/resources/latest_resources/nursing_workforce_planning_tool.html (accessed on 09 November 2009).

National health workforce planning tool. National Health Workforce Taskforce, Australia. http://www.nhwt.gov.au/researchtool.asp (accessed on 09 November 2009).

A quantitative tool for workforce planning in healthcare: example simulations. Expert Group on Future Skills Needs, Ireland, June 2009. http://www.skillsireland.ie/media/egfsn090617_healthcare_report.pdf (accessed on 09 November 2009).

Workforce configuration tool. NHS, Wales. http://www.nliah.com/portal/microsites/CMSPageDisplay.aspx?CMSPageID=313 (accessed on 09 November 2009).

Resource requirements tool. Global Health Workforce Alliance. http://www.who.int/workforcealliance/knowledge/publications/taskforces/ftfproducts/en/index.html (accessed on 09 November 2009).

There are now a wide range of freely available resources outlining strategies and experiences that have been used to address HRH issues across the world. These are a valuable source of strategies and ideas. Some useful online resources are listed below:

Asia–Pacific Action Alliance on Human Resources for Health (www.aaahrh.org)

The Global Health Workforce Alliance (http://www.who.int/workforcealliance/knowledge/en/)

The International Centre for Human Resources in Nursing (www.ichrn.org)

The HRH Global Resource Centre (http://www.hrhresourcecenter.org/ghwa_08)


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Documents

Guidelines: Nursing and Midwifery Workforce Planningapps.searo.who.int/PDS_DOCS/B4548.pdf · Adequate and competent nursing and midwifery workforce can ... limiting the progress